International Journal for Quality in Health Care 2008; Volume 20, Number 3: pp. 172 183 10.

1093/intqhc/mzn005
Advance Access Publication: 28 March 2008

Health sector accreditation research: a

systematic review
DAVID GREENFIELD AND JEFFREY BRAITHWAITE
Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales, Sydney NSW, Australia

Abstract
Purpose. The purpose of this study was to identify and analyze research into accreditation and accreditation processes.
Data sources. A multi-method, systematic review of the accreditation literature was conducted from March to May 2007. The
search identied articles researching accreditation. Discussion or commentary pieces were excluded.
Study selection. From the initial identication of over 3000 abstracts, 66 studies that met the search criteria by empirically
examining accreditation were selected.
Data extraction and results of data synthesis. The 66 studies were retrieved and analyzed. The results, examining the
impact or effectiveness of accreditation, were classied into 10 categories: professions attitudes to accreditation, promote
change, organizational impact, nancial impact, quality measures, program assessment, consumer views or patient satisfaction,
public disclosure, professional development and surveyor issues.
Results. The analysis reveals a complex picture. In two categories consistent ndings were recorded: promote change and
professional development. Inconsistent ndings were identied in ve categories: professions attitudes to accreditation,

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organizational impact, nancial impact, quality measures and program assessment. The remaining three categoriesconsumer
views or patient satisfaction, public disclosure and surveyor issuesdid not have sufcient studies to draw any conclusion.
The search identied a number of national health care accreditation organizations engaged in research activities.
Conclusion. The health care accreditation industry appears to be purposefully moving towards constructing the evidence to
ground our understanding of accreditation.
Keywords: accreditation, health care, systematic literature review, quality and safety

Introduction Many countries are embarking on accreditation programs without

Accreditation, quality and continuous improvement have
become an intrinsic part of the discourse and activities of
health services. Internationally, dating from 1970s, health
care accreditation programs and accrediting organizations
emerged and developed. There are now many national
accreditation organizations and an international body, the
International Society for Quality in Health Care (ISQua),
which has enrolled to date members in over 70 countries.
While it is fair to say that involvement in accreditation is
variable, in many parts of the world it now is an accepted
and important element in quality improvement activities.
Nevertheless, the evidence base for accreditation is thought
to be incomplete. In the accreditation literature, there have
been many calls for research into accreditation [1 8].
Commentators make the case that the evidence to support
the claims of accreditation programs is lacking. These com-
ments are representative of the concerns expressed:
any evidence that they are the best use of resources for improving
quality and no evidence about the effectiveness of different
systems and ways to implement them. [5]
One response to the call for an empirically grounded base is
a large-scale study currently in progress examining the
relationships between accreditation and organizational and
clinical performance [9]. While the anecdotal literature con-
tains argument about the value and merits of accreditation,
the evidence has not been assembled and reviewed. The
purpose of this study was to identify and analyze the research
literature on accreditation.
Methods
Search strategy
The search, using a multi-method strategy, was conducted
between March and May 2007. A similar search strategy has

Address reprint requests to: David Greenfield, Centre for Clinical Governance Research in Health, Faculty of Medicine,
University of New South Wales, Sydney NSW 2052, Australia. Tel: 612 9385 1474; Fax: 612 9385 4926;
E-mail: d.greenfield@unsw.edu.au

International Journal for Quality in Health Care vol. 20 no. 3

# The Author 2008. Published by Oxford University Press in association with the International Society for Quality in Health Care;
all rights reserved 172

been used in other pertinent reviews [10 12]. In conducting
the search, where available, citations, abstracts and complete
references were downloaded into Endnote X.0.2, a database
referencing program, for subsequent assessment.
Selection criteria
We included empirical work that systematically examined
accreditation or the accreditation process. The studies
selected centered on how accreditation works, what it does,
the results achieved and accreditation surveyors and their
processes. The selection was limited to contributions in
English.
Electronic database search
The rst search strategy was a comprehensive interrogation
of three electronic bibliographic databases. The literature was
examined from the Medline database from 1950, EMBASE
from 1980 and nursing and allied health literature from
CINAHL from 1982.
The initial search utilized the broad keywords quality,
quality assurance, quality indicators and quality of health ments. These included organizational reports and documents,
care. These keywords produced a large number and wide range
of references; the majority of which were not relevant to the
task. For example, a search in Medline with these terms
returned a result of over 2 900 000 items. After exploration and
testing two key search termsaccreditation and the Joint
Commission on Accreditation of Healthcare Organizations
or JCAHOwere identied as relevant. Within each of the
databases the search terms were searched separately. When
combined the search identied 33 935 references.
Within the results obtained, a further narrowing was
undertaken by searching for those references associated with
research, i.e. accreditation and research and JCAHO and
research. This identied 3921 references, which, with the
removal of duplicates, left a total of 3029 references.
An analysis of abstracts of these references was conducted.
This analysis identied 58 substantial studies that involved
examining accreditation via one or more research methods.
The remainder were largely discussion or commentary pieces
about accreditation or clinical research.
Identification of additional materials from
accreditation agencies
The second search strategy comprised consultation with
health sector accreditation agencies to identify additional
materials. The strategy involved searching their websites and,
where possible, through discussion with key agency person-
nel. The search included 22 national agencies and ISQua. A
number of the agencies websites were in their native
language and were either relatively inaccessible or contained
no articles which met the search criteria. While only one
published document was retrieved from this search, it ident-
ied where research into accreditation is underway. The
Research Working Group (RWG) of ISQua was rst con-
vened in October 2005 to collate information from member
Health sector accreditation research
agencies about accreditation research. The RWG-reported
research having been completed, in progress or being
planned by their member agencies. The following agencies
are currently conducting one of more studies, but have yet to
report publicly about their research: Irish Health Services
Accreditation Board (IHSAB), the United Kingdom CHKS,
Australian Council on Healthcare Standards (ACHS),
Australian General Practice Accreditation Limited (AGPAL),
Haute Autorite de sante (HAS), Italian Society for Quality of
Health Care, JCAHO, Canadian Council on Health Services
Accreditation (CCHSA) and the Spanish accreditation organ-
ization Fundacion Avedis Donabedian (FAD).
Snowballing via other databases
The third search strategy involved a snowballing technique
of following up key materials (discussion papers, articles or
reports) via the internet and search engines. The
Web-of-science, Google Scholar and Scirus internet search
engines were employed to locate documents. Literature from
1966 or since the internets inception was searched. The
snowballing technique identied an additional seven docu-
and peer reviewed articles.
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Final result of the systematic search
To summarize, the systematic search utilized three strategiesa
search of the major health bibliographic databases, consultation
with accreditation agencies and the snowballing technique.
This resulted in 66 documents meeting the search criteria.
Findings
The impact or effectiveness of accreditation programs has
been researched with a variety of foci and to differing
degrees. The 66 documents were categorized under 10
topics: professions attitudes to accreditation, promote
change, organizational impact, nancial impact, quality
measures, program assessment, consumer views or patient
satisfaction, public disclosure, professional development and
surveyor issues. These topics are summarized below.
Professions attitudes to accreditation
Some studies have examined the health professions attitudes
towards and beliefs about accreditation; key results are pre-
sented in Table 1. These present contrasting views of pro-
fessional attitudes, with both support for and criticism about
accreditation programs expressed.
In an assortment of studies, health professionals sup-
ported accreditation programs [13 18] or were in agreement
about their respective accreditation standards [19 24]. In
one study, there was a high level of support for a proposed
accreditation program [15]. Accreditation programs were sup-
ported for the following reasons: an accreditation program is
an effective strategy for assuring quality [14 16, 19],
173
D. Greenfield and J. Braithwaite

Table 1 Key results of professions attitudes to accreditation

Relevant studies Key ndings

(listed by
reference number)
.............................................................................................................................................................................

[13] A small majority of participants (medical technologists) preferred working in an accredited laboratory.
They experienced that accreditation improved the traceability of work and improved the procedures.
A large majority of participants considered that accreditation increased their workload. Two laboratories
did not think accreditation improved the quality of results. Concerns were accreditation increased
paperwork, decreased adaptability and perception that attention directed to processes rather than quality.
[14] Health professionals (incorporating nurse managers, nurses, carers and quality coordinators/managers)
generally supported the accreditation program for aged care facilities. However, health professionals also
expressed concern about a lack of consistency among assessors and the cost of the accreditation program
for aged care facilities.
[15] Stakeholders (incorporating doctors, hospital administrators, governmental ofcials and insurance
representatives) expressed a high level of support for an accreditation program (voluntary, standards
based approach, periodic external assessment and quality assurance measures). Concern was expressed
that the biggest obstacle was how to nance the accreditation program.
[16] Accredited organizations cited positive benets of the accreditation process. Most indicated that they
would reapply for accreditation. Accredited organizations discussed challenges complying with standards
and meeting the information requirements.
[17] A large majority of respondents agreed that the accreditation program had been of signicant benet to
their organization. The benets included improving communication, commitment to best practice,
information available for evaluation activities and quality care activities, improved structure for quality,

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greater focus on consumers, supporting planned change and staff management and development.
Conversely, a number of respondents stated that the accreditation program was bureaucratic, created
increased workloads and stress for staff (particularly middle managers), consumed considerable resources
and they questioned the benet to their organization.
[18] Preparations for accreditation provided hospital staff with an opportunity to reect on the operation of
the organization. At the same time, staff experienced the accreditation process as bureaucratic.
[19] Participants (allied health deans) afrmed the role of accreditation as an effective system for measuring
quality in higher education.
[20] Dentistry practitioners and program directors agreed on the importance of most experiences and
activities required by current accreditation standards.
[21] Most laboratories thought accreditation had resulted in better laboratory performance with more
documentation and better health and safety training procedures. A signicant proportion of participants
(managers/clinicians) considered accreditation to be overly bureaucratic, inefcient and expensive.
A concern that accreditation covered the domains of other regulatory bodies was also expressed.
[22] Study demonstrated that general practitioners are extremely supportive of the preparation program for
accreditation, valuing the exible, learner-centered style of the teaching and learning.
[23] Medical fellowship faculty believed that the requirements and criteria were valid for determining quality
of faculty development fellowship programs. The accreditation process was also considered by faculty
staff to be time-consuming and they thought that it could be shortened.
[24] Purchasers had a keen interest in health plan accreditation and relied heavily on accreditation decisions
when choosing which plans to offer their beneciaries. Purchasers also wanted to understand the
strengths and weaknesses of the accreditation process for their own contracting purposes.
[25] Doctors were unaware or sceptical of accreditation. They held concerns about how safety and quality of
care should be measured. Doctors perceived themselves to be accountable within a professional
framework (self/patient/colleagues) not to the organizations in which they worked.
[26] Senior staff s principal concerns of an accreditation program were related to perceptions that the process
is unwieldy and it offers little value for patient care delivery for the resources required. Signicant levels
of negative feedback were received.
[27] The study examined the small hospital accreditation scheme in the United Kingdom. The program
(including visits by independent surveyors) was valued by respondents who were also keen to see it
continue to evolve.
(continued )

174

Table 1 Continued
Relevant studies Key ndings
(listed by
reference number)
.............................................................................................................................................................................
[28] Respondents (hospital administrators) explained that the largest factor contributing to rural hospital
deterrence to seeking accreditation was cost.
[29] Healthcare professionals (physicians, dentists, pharmacists, and nurses) had been facing many problems
with multidisciplinary process-related issues of an accreditation standard. Surveyors experienced
difculties in conveying the core quality improvement concepts to the professionals.
accreditation results in better organizational performance [13,
14, 17, 21] and enables collegial decision-making [17, 18]
and accreditation provides a guide to external stakeholders to
how quality and safety is managed within an organization
[16, 18, 24]. However, all studies with one exception, which
recorded improvements due to accreditation [21], did not
attempt to examine the impact of the programs.
Other researches report health professionals critical per-
spectives on accreditation. These studies suggest that
health professionals hold concerns about their respective
accreditation programs, including the program is bureau-
cratic and time consuming for the organization to use
[13, 14, 16 18, 21, 23, 25, 26], the program is perceived
to add little value to patient care [25, 26], there are high
(direct and indirect) costs of the program [21, 26 28],
there is a perceived lack of consistency among assessors
[14, 17] and there are problems with accreditation stan-
dards [29]. One further study, an Indian study examining
stakeholder views about the proposed introduction of an
accreditation program, identied caution about the pro-
posed program [15].
The research into the views of health professionals about
accreditation is patchy, with some professions or groups
opinions examined and others unexplored. Two studies
assessed the views of doctors about hospital accreditation
programs. Doctors considered such programs were not rel-
evant to them. Instead, they viewed their professional
forums as more appropriate in addressing issues of practice
standards and quality [18, 23, 25]. Nurse managers were
most positive about and motivated to participate in an
accreditation process due to their organizational responsibil-
ities [14, 18]. Health managers were reported to be positive
about accreditation, identifying it as a strategic issue by
which to inuence care processes [16, 18]. Allied health
deans also perceived accreditation favorably [19], as did lab-
oratory managers and medical technologists [13, 21], aged
care service providers (incorporating nurse managers,
nurses, carers and quality coordinators/managers) [14], den-
tistry practitioners and program directors [20] and stake-
holders (including doctors, hospital administrators,
governmental ofcials and insurance representatives) in a
country where the introduction of a program was being
considered [15]. Similarly, purchasers of health services
regarded accreditation positively as it provided them with a
guide to the quality of the services they were examining
Health sector accreditation research
[24, 27, 30]. Professionals from rural health services have
been asked their reasons for failing to participate in an
accreditation program [16, 28]. The most signicant barriers
identied were cost [28], difculty in meeting standards and
collecting data [16].
Promote change
The activity of preparing and undergoing accreditation has
been shown to promote change in health organizations [18,
31 33]; key results are presented in Table 2. A study in
Australia monitored for 2 years a group of 23 hospitals
which applied for accreditation and then compared them
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with those which had not. The accredited hospitals showed
signicant change in six areas, most notably in nursing
organization and safety [31]. Research in one organization
revealed changes instigated by accreditation as it provided an
opportunity for health professionals to reect on organiz-
ational practices. The organization then reportedly changed
policy, decision-making behaviors and introduced a continu-
ous quality program [18]. Similarly, participating in an accred-
itation program and a randomized clinical trial led to
signicant improvements in both the dissemination and the
quality of clinical guidelines [33]. A review of the develop-
ment of several accreditation programs noted their conver-
gence and widespread impact on both individual
organizations and at a system level [32].
Organizational impact
The organizational impact of accreditation programs remains
unclear; key results are presented in Table 2. One study
failed to identify any differences between accredited and non-
accredited (rehabilitation) programs [34]. Another study
found improved outcomes when a (trauma) health service
was accredited [35]. A review of accredited hospitals in
France showed no signicant differences in accreditation
decisions according to their status and size [36]. However, a
trend was identied that larger hospitals received more
numerous and serious recommendations.
A study reported enhancements to patient care through
three organizational strategies introduced as a result of parti-
cipating in an accreditation program [37]. The strategies were
a patient communication strategy, an evaluation strategy and
a quality improvement strategy. A participative management
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D. Greenfield and J. Braithwaite

Table 2 Key results of promote change and organizational impact

Relevant studies Key ndings

(listed by reference
number)
.............................................................................................................................................................................

[18] Preparations for accreditation provided hospital staff with an opportunity to reect on the operation
of the organization. It enabled the introduction of a continuous quality program, greater consideration
of exit surveys and improved procedure documentation.
[31] Accredited hospitals could be differentiated by signicant changes in six areas: administration and
management, medical staff organization, review systems, organization of nursing services, physical
facility and safety, hospital role denition and planning. Most affected were nursing organization and
physical facilities and safety; least change was found in areas most directly associated with medical
staff.
[32] Different countries have adopted similar accreditation programs. However, they were implementing
and adapting their accreditation programs to meet their specic policy needs.
[33] Hospital combining both a clinical trial and participation in an international accreditation program led
to a signicant improvement of both dissemination and quality of guidelines on perioperative diabetic
care.
[34] Survey of accredited and non-accredited (rehabilitation) programs suggested no signicant differences
in the organization and delivery of cognitive rehabilitation therapy.
[35] Development of a trauma program and commitment to meeting national guidelines through the
accreditation process appeared to be associated with improved outcome after injury.
[36] The study showed wide heterogeneity in the summaries on accreditation and in accreditation agency
decision-making for different size and status hospitals. Also provided initial insight into common

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quality defects and priorities for hospitals.
[37] Described a program, developed to meet an accreditation standard, that helped focus a large acute
private hospital on patients.
[38] The manager was the most important entity in achieving a successful accreditation outcome.
Managers, who were perceived as participative, have more years of experience, had written more
self-studies, and whose faculty support the accreditation process, were likely to have more positive
accreditation outcomes.

style and an organizational support for the accreditation
process have been shown to affect the outcome
positively [38].
Financial impact
The nancial costs of accreditation for organizations are an
under-researched area. There are contrasting assessments
made in the few studies that have been conducted; key
results are presented in Table 3. Three studies judged the
costs to be high for individual organizations and ques-
tioned whether accreditation was an appropriate use of
resources [14, 26, 39]. In examining an accreditation
program in a developing country, one study found that the
overall nancial viability of the program and costs for indi-
vidual organizations was unsustainable [40]. Another study
noted the costs incurred in participating in accreditation,
and argued that these should be viewed as an essential
investment [30].
A recent work examined the costs for a specic health
service (methadone treatment sites). It concluded that there
were no signicant nancial differences for organizations of
different size and location [41]. However, the study also
reported that per-patient accreditation costs were substantially
larger for small and rural organizations compared with
medium to large and urban locations.
Quality measures
Quality measures incorporate items dened as clinical indi-
cators, quality indicators or clinical performance measures.
The relationship between quality measures and accreditation
is complex; key results are presented in Table 4. In some
work, there does not appear to be a direct relationship
between the two. No relationship is generally found between
a specied quality measure and an accreditation outcome
[42 45]. One study showed that improved compliance with
accreditation standards had little or no effect on clinical indi-
cator performance [46]. A weak relationship between accredi-
tation and quality measures was identied in one instance
[47]. In a similar vein, a relationship did hold for health plan
scores when compared with accreditation [42]. However, in
the same study, accreditation and patient-reported measures
of quality and satisfaction were found to be unrelated.
For some time, accreditation agencies have been develop-
ing, implementing and monitoring quality measures in health
care organizations. While not always an essential part of their
respective accreditation programs, some quality measures

176
 Health sector accreditation research

Table 3 Key results of nancial impact

Relevant studies Key ndings

(listed by
reference number)
.............................................................................................................................................................................

[14] Health professionals expressed concern about the cost of the accreditation program for aged care
facilities.
[26] Senior staff s principal concerns of an accreditation program were related to perceptions that the process
was unwieldy and it offered little value for patient care delivery for the resources required.
[30] A study of expenditures in accreditation argued that the costs should be seen as an essential investment
and demonstration of commitment to quality.
[39] Case study of a neuropsychiatric hospital which questioned whether the quality of care was improved by
the accreditation process and the costs constitute an appropriate use of resources.
[40] Serious resource constraints, both nancial and expertise, had undermined the ongoing viability of the
Zambian hospital accreditation program.
[41] Methadone treatment sites faced similar accreditation costs regardless of characteristics such as size and
location. Rural and smaller sites incurred a greater burden from accreditation. There was no signicance
difference in cost for a site regardless of accreditation outcome; nor did previous accreditation affect the
cost.
Accreditation preparation costs were the majority of the total expenditure, with the majority of
preparation in the nal months prior to survey. Preparation for accreditation was seen as labor intensive.

Table 4 Key results of quality measures

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Relevant studies (listed Key ndings
by reference number)
.............................................................................................................................................................................

[42] A study to determine the characteristics of accredited plans, their performance on quality
indicators and the impact on enrolment. The results showed accreditation did not ensure
high-quality care. It is positively associated with some measures of quality, but it did not ensure
a minimal level of performance.
[43] During an accreditation survey, experienced surveyors failed to detect an error-prone medication
usage system (shown by an independent audit). This raised questions about the validity of
survey scores as a measure of safety.
[44] There was a potentially serious disjuncture between outcome measures and accreditation
evaluations. Data showed no relationship of substance, and a confusing pattern of minor and
sometimes conicting associations.
[45] No signicant relationships existed between categorical accreditation decisions (JCAHO) and
quality indicators.
[46] Those hospitals participating in an accreditation program improved their compliance with
accreditation standards; non-participating hospitals did not. However, there was no observed
improvement on the quality indicators.
[47] Analysis revealed a weak relationship between accreditation or certication status and the
indicators of quality of care (the characteristics examined were average cost per patient, per diem
bed cost, total staff hours per patient, clinical staff hours per patient, percent of staff hours
provided by medical staff bed turnover, and percent of beds occupied). Accredited or certied
hospitals were more likely to have higher values on specic indicators than hospitals without
accreditation.
[48] Clinical indicators were reported to have become an accepted part of hospital quality
improvement activities. The inclusion of clinicians in indicator development, along with regular
feedback had resulted in their extensive use, and many actions to improve patient care.
[49] An accrediting agency provided feedback to organizations on their quality indicator data.
A signicant majority of organizations responded to this feedback to improve both the
processes and outcomes of patient care.
(continued )

177
D. Greenfield and J. Braithwaite

Table 4 Continued

Relevant studies (listed Key ndings

by reference number)
.............................................................................................................................................................................

[50] A self-evaluation project allowed health services to monitor their own activities in order to asses
critical factors related to patient care. The project had the potential to be the starting point to
improve the quality of services and to compare national and international quality assurance
results.
[51] Quality indicator performance measures encouraged organizations to seek improvements in
patient care (data showed improvement in 15 of 16 inpatient measures).
[52] Including discharge instructions among other evidence-based heart failure core measures
appeared to reduce re-admission or mortality.
[53] Feedback to hospitals on their clinical indicator performance produced consistent improvement
over the study period. Hospitals initially with low levels of performance had greater
improvements than those with higher performance.
[54] A study examining the value of self-reporting standardized performance indicators for hospitals.
Symmetry of disagreement among original abstractors and re-abstractors identied eight
indicators whose differences in calculated rates were statistically signicant.
[55] A study comparing organizations with and without quality improvement activities: the effects of
self-reported quality improvement activities were often small and inconsistent, and in some
instances contrary to expectations.
[56] It was faulty to assume that clinical indicators derived from different measurement systems will
give the same rank order.
[57] Hospitals that participate in a quality improvement program were no more likely to show

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improvement on quality indicators than were hospitals that did not participate.
[58] Medication errors were found to be common in a stratied random sample of organizations. A
signicant number (7%) of potentially harmful errors were identied. Accreditation of a facility
was not associated with a lower error rate.
[59] The association between quality of care and survival for acute myocardial infarction was
examined for accredited and non-accredited hospitals. Non-accredited hospitals displayed lower
quality than accredited hospitals. However, there was considerable variation in performance
among accredited hospitals.

have been shown to improve care outcomes in health organ- Program assessment
izations [48 54]. Similarly, participation in an accreditation
Accreditation programs have been assessed and researched
program and a randomized clinical trial promoted improve-
for their validity [17, 21, 23, 27, 43, 60 64]; key results are
ment in a quality measure, in this instance a clinical guideline
presented in Table 5. The ndings from this research are
[33]. However, another study found that the effects of
inconsistent. Accreditation programs in six studies were
quality improvement activities were often small and inconsist-
deemed to be credible [17, 21, 23, 27, 61, 62]. The validity
ent [55]. An important argument has been made that differ-
of accreditation programs was questioned in other cases and
ent quality measures, developed and implemented in
authors have argued for the need for improvements in or
different ways, should not be expected to promote similar
clarication of standards [21, 60, 63, 64]. In one instance,
outcomes [56].
the validity of an accreditation program as a measure of
Conicting ndings hold in comparing accredited and
patient safety was questioned, based on its failure to identify
non-accredited hospital quality indicator performance.
an error-prone medication usage system [43].
Quality indicator results from hospitals that voluntarily par-
Two descriptive studies examined the development or
ticipate with quality improvement organizations could not be
implementation of accreditation programs in developing
differentiated from those hospitals that do not participate
countries [40, 65]. In one, the milestones achieved and chal-
[57]. Similarly, no difference could be found between accre-
lenges facing the program were detailed [40]. In the other,
dited hospitals, non-accredited hospitals and nursing homes
an overview of the program and its development was
for medication errors [58]. However, another study revealed
presented [65].
that accredited hospitals performed better on a range of
An argument has been made in favor of specialized organ-
quality indicators than did non-accredited hospitals, albeit
izations that perform accreditation and establish standards
there was considerable variation of performance within the
for healthcare delivery, at least in the United States [66].
accredited hospitals [59].

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 Health sector accreditation research

Table 5 Key results of program assessment

Relevant studies Key ndings

(listed by
reference number)
.............................................................................................................................................................................

[17] A large majority of respondents agreed that the accreditation program had been of signicant benet
to their organization. The benets included improving communication, commitment to best practice,
information available for evaluation activities and quality care activities, improved structure for quality,
greater focus on consumers, supporting planned change and staff management and development.
[21] Most laboratories thought accreditation had resulted in better laboratory performance with more
documentation and better health and safety training procedures. However, a signicant proportion of
laboratories considered accreditation to be overly bureaucratic, inefcient and expensive. A concern
that accreditation covered the domains of other regulatory bodies was also expressed.
[23] Medical fellowship faculty believed that the requirements and criteria were valid for determining
quality of faculty development fellowship programs. However, the accreditation process was
considered by faculty staff to be time-consuming and they thought that it could be shortened.
[27] The study examined the small hospital accreditation scheme in the United Kingdom. The program
(including visits by independent surveyors) was valued by respondents who were also keen to see it
continue to evolve.
[40] Serious resource constraints, both nancial and expertise, had undermined the ongoing viability of the
Zambian hospital accreditation program.
[43] During an accreditation survey experienced surveyors failed to detect an error-prone medication usage
system (shown by an independent audit). This raised questions about the validity of survey scores as a
measure of safety.

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[60] The study developed eight models by which to classify the process of evaluation criteria applied to the
nursing services adopted by accreditation programs.
[61] The study developed a framework and assessment tool which offers patients and other stakeholders a
credible measure of quality and safety at the practice level. The tool was developed through a process
bridging quality control and quality improvement.
[62] A protocol to evaluate the capacity of special care units to provide quality care was evaluated. The
standards used, their intent and the survey process, were considered sound by those who tested the
protocol and by those who were evaluated by it.
[63] The current design of a radiology accreditation phantom program was unsatisfactory for assessing
image quality in digital mammography.
[64] In examining the efcacy of accreditation standards applied to medical specialists the study concluded
that there is an imbalance between the setting of standards and their implementation.
[65] The accreditation program for hospitals in South Africa is deemed to be benecial.
[66] The uniqueness of each accrediting organization and their program and standards was noted.
Different organizations were better suited to accredit specic areas of health.

While leaving open the question as to whether such accredit-
ing organizations are ensuring high-quality healthcare, the
authors express support for the range of specialized accredit-
ing organizations and programs. The difculties experienced
by an accrediting organization in the United Kingdom have
also been examined. The study suggested that there was an
imbalance between setting and implementing the standards
of the accreditation program [64].
Consumer views or patient satisfaction
Although the relationships between consumer views or
patient satisfaction and accreditation remain largely unex-
plored, the limited work that has taken place found no
relationships [42, 67, 68]; key results are presented in
Table 6. An examination of the relationship between
not-for-prot hospital accreditation scores and patient satis-
faction ratings found no association, either summatively or
formatively [67]. Similarly, patient-reported measures of
quality and satisfaction between accredited and non-
accredited health plans could not be differentiated [42].
Patients and health professionals views about compliance
with accreditation standards have been compared. While differ-
ing in specic details, the satisfaction rank-order correlations
for the two groups were similar [69]. A survey of patients
during the accreditation of general practices showed patients
scored practice issues (access, availability and information avail-
ability) lower than doctors interpersonal skills [68].

179
D. Greenfield and J. Braithwaite

Table 6 Key results of consumer views or patient satisfaction, public disclosure, professional development and surveyor
issues

Relevant studies Key ndings

(listed by
reference number)
.............................................................................................................................................................................

[42] A study to determine the characteristics of accredited plans, their performance on quality indicators
and the impact on enrolment. The results showed accreditation did not ensure high quality care. It is
positively associated with some measures of quality, but it did not ensure a minimal level of
performance.
[67] No relationships were identied between hospital accreditation scores and patient-satisfaction ratings,
suggesting a dissociation between them.
[68] As part of an accreditation program for general practices patient views were examined. Patients
considered that doctors need to improve interpersonal skills, access, availability and patient
information.
[70] The study showed a positive association between accreditation scores and public disclosure of
accreditation reports of hospitals.
[71] Students who attended an accredited paramedic program were more likely to achieve a passing score
on a national paramedic credentialing examination.
[72] There were signicant positive relationships between accreditation afliation of nursing programs and
membership in professional nursing organizations and between accreditation afliation of nursing
programs and major contributing factors used to select accrediting agencies.
[73] A re-accreditation program was having benecial effects (increasing the amount and type of activities)
on the continuing medical education activities of many participating general practitioners.

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[74] Graduates from accredited nursing education programs did not perform better than those from
non-accredited programs.
[27] The study examined the small hospital accreditation scheme in the United Kingdom. The program
(including visits by independent surveyors) was valued by respondents who were also keen to see it
continue to evolve.
[29] Healthcare professionals (physicians, dentists, pharmacists, and nurses) had been facing many
problems with multidisciplinary process-related issues of an accreditation standard. Surveyors
experienced difculties in conveying the core quality improvement concepts to the professionals.
[75] A comparative study of how different accreditation agencies managed surveyors. Surveyors around the
world share many common features in terms of careers, training, work history and expectations.

Public disclosure Professional development

A study examined the impact of accreditation outcome and
public disclosure [70]; key results are presented in Table 6.
The work, conducted in Japan, yielded several ndings:
accreditation scores were positively related to public disclos-
ure of hospital accreditation reports, public hospitals were
signicantly more likely to publicly disclose than private hos-
pitals, larger hospitals were signicantly more likely to partici-
pate in public disclosure than smaller hospitals, hospitals in
rural areas were more likely to disclose than those in urban
settings and disclosing hospitals scored higher than non-
disclosing hospitals on measures of patient focused care and
efforts to meet community needs. Public disclosure was con-
sidered by a majority of respondents as good for consumers
and hospitals; however, concern was expressed about the
public reaction to lower accreditation scores. A signicant
number of hospitals who disclosed their accreditation reports
perceived that disclosure provides incentives for improve-
ment and increases the credibility of hospitals with their
community.
A link between accreditation programs and the development
of health professionals has been established; key results are
presented in Table 6. The association has been shown to be
positive [71 73]. However, dissenting ndings have been
noted [74].
A study revealed that health professionals who received
training in an accredited education program were more likely
to pass a professional credentialing exam than their col-
leagues in a non-accredited program [71]. Extending this
nding, an accreditation program had a small but benecial
impact on the ongoing professional education of health
(medical) professionals [73]. Accreditation afliation of a
health education program has been shown to have a positive
inuence on individuals seeking professional organization
membership [72].
The accreditation of a health program appears unrelated
to professional performance [74]. No distinction between the
conduct of health professionals who trained or did not train
in an accredited program could be distinguished in the rst

180

year. Counter-intuitively, in the second year, the performance
of those who trained in a non-accredited program was
assessed to be better than their colleagues from accredited
programs.
Surveyor issues
Research into accreditation surveyors is limited; key results
are presented in Table 6. One study examined the skills and
qualities of surveyors and the challenges they faced when
undertaking accreditation surveys [27]. A comparative study
examined the similarities and differences of surveyors across
six accreditation programs [75]. A more recent Thai study,
which also considered the opinions of health professionals,
demonstrated that both groups shared a similar prioritizing
of concerns. The surveyors focused more attention on
care-related items than did the health professionals, who
were focused on multidisciplinary process-related problems
associated with the program [29].
Discussion and conclusion
Although we searched in a multi-method, comprehensive
manner, electronic research indexing is generally problematic
and we may have missed some key literature. Searching rel-
evant accreditation bodies websites and personally contacting
agencies to gather data yielded additional references and
information of value.
The necessity for an empirically grounded, comprehensive
evidence base for accreditation has long been recognized.
Without this, the varying positive and negative views about
accreditation will remain anecdotal, inuenced by ideology or
preferences, and driven by such biases.
This review of health care accreditation research literature
reveals a complex picture. There are mixed views and incon-
sistent ndings. Only in two categories were consistent nd-
ings recorded: promote change and professional
development. Inconsistent ndings were identied in ve cat-
egories: professions attitudes to accreditation, organizational
impact, nancial impact, quality measures and program
assessment. In the remaining three categoriesconsumer
views or patient satisfaction, public disclosure and surveyor
issueswe did not nd sufcient studies to draw
conclusions.
A positive note to emerge from this research has been the
identication of a number of national health care accredita-
tion organizations and researchers presently engaged in
empirical activities. They seem to be engaged in purposeful
work leading towards constructing an extensive evidence
base.
Acknowledgements
The research was conducted by researchers in the Centre for
Clinical Governance Research at University of New South
Wales, Sydney, Australia, and forms part of the Centres
Health sector accreditation research
research program into accreditation. For this research the
Centre has industry partners the Australian Council on
Healthcare Standards and Ramsay Healthcare.
Funding
This research was supported under Australian Research
Councils Linkage Projects funding scheme ( project number
LP0560737).
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Accepted for publication 18 January 2008
183